1. Integration of HRH in MNCH and HIV services Director of Human resources development

2. Session outline Defining integration context. Enabling and constraining factors The concepts of systems “hardware” vs. systems “software”

3. Do we know it when we see it? What does integration look like? From the perspective of a consumer of health services (e.g., a patient) From the perspective of a provider of health services (e.g., a clinician) From the perspective of a manager of health services (e.g., a facility manager, or DHMT) From the perspective of a steward of health services (e.g., a health Ministry)

4. Integration of services The integration of clinical services at the point of care can be thought of as services integration: – Integration of clinical services for HIV and TB – Integration of Clinical services for MNCH and PMTCT – Integration of services for infants and Children (IMCI)

5. Integration – the ‘What’ The “ what ” of integration asks about structures, functions and processes, as well as the convergence of professional cultures, norms and working methods

6. What Are we Integrating?

7. Adding detail to a vision

8. Promising Practices: Facility level Unified primary care teams Mobile (drop‐in) teams Harmonized health information systems / records Integrated service‐delivery protocols Integrated case management tools (provider support tools, HMIS, registers etc.) Facility level team building exercises Task shifting Community engagement and outreach

9. Promising Practices: program level Use of multidisciplinary teams Guidelines step‐by‐step SOPs Integrated training curricula/materials Integrated case management tools (provider support tools, HMIS, registers etc.) Integrated M&E with joint targets and reports

10. Promising Practices: National level Strong political leadership, effective national management, joint policy and coordination mechanisms (ex: joint technical working groups) National targets for collaborative activities Creation of a strong policy environment (with policy and operational guidelines and training manuals) Attention to availability of supplies and commodities Ongoing supervision/mentorship/M&E Buy in from/engagement of donors

12. Integration of HIV and MNCH Services Enabling Factors Stakeholder support Relatively simple, inexpensive interventions added to existing services Staff experience & buy‐in Substantial investment in training and supervision Integrated electronic patient record systems across services Client (and partner) acceptance and convenience Emphasis on quality of care Constraining Factors Limited financial resources Staff turnover High workload and resistance to changing practices Additional referral waiting time and user costs/fees Cost and logistics of commodity procurement Client fear re: breach of confidentiality

13. HARDWARE Simple, inexpensive interventions added to existing services Integrated electronic patient record systems across services Investment in training Software Limited financial resources High workload Cost and logistics of commodity procurement Lack of skills / capacity Additional user costs/fees Constraining Enabling Software Resistance to changing practices (patients/providers/officials) Vested interests & local power dynamics Staff turnover Additional referral waiting time Stakeholder support Staff experience & buy‐in Investment in supervision Emphasis on quality of care HARDWARE

14. Common Implementation Strategies Mainstreaming SoPs New or harmonized guidelines Decentralized ART services Addition of HCW Training of HCW Harmonized patient flow Harmonized medical info.

15. Implementation requires balance b/w hardware and software strategies Implementation strategies for integration often focus most heavily on hardware components because they are: – easier to identify – (somewhat) easier to change – (significantly) easier to measure But many of the enduring barriers to sustainable integration occur in the software domain e.g: – Lack of political will – Lack of local buy in – Work place norms Assessing or planning for integration means mapping out both hardware and software components

16. Results: on Stigma “Nowadays there is less stigma because no one will identify who is positive or negative. We are in the same queues, same files and cards, we go to same pharmacy etc.” [OPD patient ; POST implementation] Topp et all, PloS One, 2010

19. Results: team work “Nowadays there is no division that this work is for OPD or ART. Since the integration everyone is working together we are one.” [Clinician ] “Work culture is much improved because of shared responsibility…. Staff are easier to manage because they are working together”. [health centre in-charge]

20. Thank you for listening